MEDICARE: MANASHIR RUVINOV

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	F352190-01	NY

General Provider Information

NPI Number	:	1356936108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANASHIR RUVINOV

Provider Business Mailing Address
First Line	:	1375 CONEY ISLAND AVE
Second Line	:	PMB 1000
City	:	BROOKLYN
State	:	NY
Zip	:	11230-1116
Country	:	US
Telephone Number	:	917-545-2292
Fax Number	:

Provider Business Practice Location Address
First Line	:	331 KINGS HWY STE A
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11223-1443
Country	:	US
Telephone Number	:	646-995-9999
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2021
Last Update Date	:	10/18/2024

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